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120 present or have been members of regular Lodges; that having the prosperity of the fraternity at heart, they are willing to exert their best endeavors to promote and diffuse the genuine principles of Freemasonry; that for the conveniency of their respective dwellings [otherwise, stating the circumstances of the case], and for other good reasons, they have agreed to form a new Lodge; that in consequence of this resolution, they pray the Most Worshipful Grand Master for a dispensation to empower them to assemble as a regular Lodge at. . . . and there to discharge the duties of Freemasonry in a regular and constitutional manner, according to the ancient usages of the Order, and the rules and regulations of the Grand Lodge of Ancient Freemasons of. . . . . . . . . . . ; that they have nominated and do recommend A. B. to be the first Master, and C. D. to be the first Senior Warden, and E. F. the first Junior Warden of the said Lodge: and the prayer of this petition being granted, they promise strict conformity to every regular edict and command of the Grand Master, and to the constitutions, laws, and regulations of the Grand Lodge of Ancient Freemasons of. . . . . . ..

This petition must be signed by, at least, seven regular Master Masons, and be recommended by the nearest Lodge, and be delivered to the Grand Secretary, who shall present it to the Grand Master, or, in his absence, to the Deputy Grand Master. If the application shall be approved, the Grand Secretary is ordered to grant a dispensation in the following words:

To all whom it may concern:

, we. . . . . . Most Worshipful Master of Ancient Freemasons of. . . . . . . . ,